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4 <br /> t ' <br /> l APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I- YEAR FROM DT ISSUED <br /> (Complete in Triplicate) <br /> ` r Application is hereby msde.to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> l application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> [[[ Joaquin County Public Health Services. <br /> Job Address cFN& City Lot Size/Acreage nsat..... <br /> .4.41 <br /> �l�y�a <br /> Owner's Name <br /> Address f1 4-�� Phone <br /> � <br /> e fdZl� r� , . <br /> A Contractor -Address._ ISD 1.�� �License No. Phone �'s ! <br /> TYPE OF WELL/PUMA: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well CI <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER, E) Monitoring <br /> P; DISTANCE TO NEAREST: SEPTIC TANK� SEWER LINES DISPOSAL FLD <br /> —. . PROP. LINE 11-4-99 ¢i <br /> FOUNDATION __�C.— AGRICULTURE WELL OTHER WELL -`p! PITS/SUMPS =� <br /> Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl'�Industriai, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1 Domestic/Private iravef Pack ❑ Tracy Type of Casing_ /,.,� Specifications,. s:.� 1A!Q! <br /> 1'1 Public 1-1 Other Cl Delta Depth of Grout Seal ��=�1�_— Type of Grout <br /> I ! Irrigation �7 Approx. Depths`I9I Eastern Surface Seal Installed by �S89Z . Z� '�-- <br /> Repair Work'Done L7 Type of Pump H.P. 7-- State Work Done ' <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth ., <br /> Depth Tiller Material i Depth ;, <br /> II TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION I I lNo septic system permitted if public sewer is <br /> t available within 200 feet.) r <br /> Installation will serve: Residence_-_. Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sols to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compare nts <br /> i PKG. TREATMENT PLT.❑ e Method of Disposal <br /> F <br /> Distance to.nearest: Well Foundation Property Line <br /> y <br /> LEACHING LINE ❑ No. & Length of.linea ' Total length/size <br /> FILTER BED ❑ Distance to nearest" 'well j Foundation Property Line <br /> I _ <br /> SEEPAGE PITS 11 Depth f' Size. Number <br /> 't. SUMPS LI Distance to nearest: . Well .:. *Foundation Property Line <br /> I a� DISPOSAL PONDS ❑ <br /> f' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws;and <br /> Arules and regulations of the San Joaquin County _0 <br /> I{ Home owner or licensed agent's signature certifisi the following; "I.certify that in the performance of the work for which this permit is issued, I$hall'not r <br /> employ any person in such manner as to become subject-to workman's compensation laws of California." Contractor's hiring or sub-contracting signature k <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's eompensa � <br /> 'tion laws of California." `�' k <br /> s The applicenAn r r ctions. Complete drawing on revert side. jI . t <br /> Signed Title <br /> � �� Date: 1 <br /> ` FOR DEPARTMENT USE ON <br /> Application Accepted by Date �' Area ' <br /> ! Pis or�Inspection by Date Final Inspection by be <br /> nA`ditionak comrr,.ntt-�- _ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ,x <br /> Environmerit -1 Health Permit/Services <br /> 445 N Sds Jbaquih NP O Box:2009; Stkn, CIL 95201 � <br /> FEE AMOUNT pt1E AMOUNT REMITTED K RECEIVED BY BATE PERMiT'NO. <br /> INFO CASH C <br /> EM 13$401EV.iinsi <br /> EH 14.3! P k40'_ ` <br />